Clinical Judgment, Clinical Decision Rules, and Evidence-Based Medicine: Thoughts on “An Observation of Failure to Validate the San Francisco Syncope Rule”

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To the Editor:

Birnbaum et al¹ report in their validation study of the San Francisco Syncope Rule that 26% of patients with serious outcomes were not identified by the rule. They also report that physician judgment without application of the prediction rule resulted in admission of all 61 (100%) subjects who experienced serious outcomes. What we cannot glean from the article is how the clinicians formulated that judgment.

This critical but undefined component of decisionmaking receives far less attention than those components that are easily measured and therefore quantifiable. As a specialty we must learn more about how these judgments are formed, what clinical information leads to final disposition decisions in general, and specifically how this applies to syncope.

Recently we have seen the implementation of checklists in medicine as a successful means of decreasing central line infections in the intensive care setting. The results have been laudable. The use of checklists in medicine has been compared to the use of checklists by airline pilots.² These are only comparable to a limited extent. The use of checklists is perfect for ensuring that protocol is followed where safety issues are clearly defined, but during an emergency the judgment of a skilled pilot or physician will often be preferable to a rule.

Is it surprising that judgment was better than the San Francisco syncope rule? Probably not. Until we have adequately researched and probed the element of physician judgment, and are able to integrate this data into clinical decision rules, it is best to remember that physician judgment should never be replaced by rules, and rules should be used only as a reference to assist judgment.

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References 

1. Birnbaum A, Esses D, Bijur P, et al. Failure to validate the San Francisco Syncope Rule in an independent emergency department population. Ann Emerg Med. 2008;52:151–159
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2. Groopman J. How Doctors Think. Houghton Mifflin Company; 2007;
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